HIT 120 review

audit trail

1. A chronological set of computerized records that provides evidence of information system activity (logins and logouts, file accesses) used to determine security violations 2. A record that shows who has accessed a computer system, when it was accessed, and what operations were performed

confidentiality

1. A legal and ethical concept that establishes the healthcare provider's responsibility for protecting health records and other personal and private information from unauthorized use or disclosure 2. As amended by HITECH, the practice that data or information is not made available or disclosed to unauthorized persons or processes (45 CFR 164.304 2013)

data model

1. A picture or abstraction of real conditions used to describe the definitions of fields and records and their relationships in a database 2. A conceptual model of the information needed to support a business function or process

auto-authentication

1. A procedure that allows dictated reports to be considered automatically signed unless the health information management department is notified of needed revisions within a certain time limit 2. A process by which the failure of an author to review and affirmatively either approve or disapprove an entry within a specified time period results in authentication

case management

1. A process used by a doctor, nurse, or other health professional to manage a patient's healthcare (CMS 2013) 2. The ongoing, concurrent review performed by clinical professionals to ensure the necessity and effectiveness of the clinical services being provided to a patient

standard

1. A scientifically based statement of expected behavior against which structures, processes, and outcomes can be measured 2. A model or example established by authority, custom, or general consent or a rule established by an authority as a measure of quantity, weight, extent, value, or quality 3. Under HITECH, a technical, functional, or performance-based rule, condition, requirement, or specification that stipulates instructions, fields, codes, data, material, characteristics or actions (45 CFR 170.102 2012) 4. As amended by HITECH at section 160.103, a rule, condition, or requirement: (1) describing the following information for products, systems, services, or practices: (i) classification of components; (ii) specification of materials, performance, or operations; or (iii) delineation of procedures; or (2) with respect to the privacy of protected health information (45 CFR 160.103 2013)

standard

1. A scientifically based statement of expected behavior against which structures, processes, and outcomes can be measured 2. A model or example established by authority, custom, or general consent or a rule established by an authority as a measure of quantity, weight, extent, value, or quality 3. Under HITECH, a technical, functional, or performance-based rule, condition, requirement, or specification that stipulates instructions, fields, codes, data, material, characteristics or actions (45 CFR 170.102 2012) 4. As amended by HITECH at section 160.103, a rule, condition, or requirement: (1) describing the following information for products, systems, services, or practices: (i) classification of components; (ii) specification of materials, performance, or operations; or (iii) delineation of procedures; or (2) with respect to the privacy of protected health information (45 CFR 160.103 2013)

source system

1. A system in which data was originally created 2. Independent information system application that contributes data to an EHR, including departmental clinical applications (for example, laboratory information system, clinical pharmacy information system) and specialty clinical applications (for example, intensive care, cardiology, labor and delivery)

accreditation

1. A voluntary process of institutional or organizational review in which a quasi-independent body created for this purpose periodically evaluates the quality of the entity's work against preestablished written criteria 2. A determination by an accrediting body that an eligible organization, network, program, group, or individual complies with applicable standards 3. The act of granting approval to a healthcare organization based on whether the organization has met a set of voluntary standards developed by an accreditation agency

authorization

1. As amended by HITECH, except as otherwise specified, a covered entity may not use or disclose protected health information without an authorization that is valid under section 164.508 2. When a covered entity obtains or receives a valid authorization for its use or disclosure of protected health information, such use or disclosure must be consistent with the authorization (45 CFR 164.508 2013)

grouper

1. Computer program that uses specific data elements to assign patients, clients, or residents to groups, categories, or classes 2. A computer software program that automatically assigns prospective payment groups on the basis of clinical codes

critical access hospital

1. Hospitals that are excluded from the outpatient prospective payment system because they are paid under a reasonable cost-based system as required under section 1834(g) of the Social Security Act 2. Under HITECH incentives, a facility that has been certified as a critical access hospital under section 1820(e) of the Act and for which Medicare payment is made under section 1814(l) of the Act for inpatient services and under section 1834(g) of the Act for outpatient services (42 CFR 495.4 2012)

health record

1. Information relating to the physical or mental health or condition of an individual, as made by or on behalf of a health professional in connection with the care ascribed that individual 2. A medical record, health record, or medical chart that is a systematic documentation of a patient's medical history and care

managed cared

1. Payment method in which the third-party payer has implemented some provisions to control the costs of healthcare while maintaining quality care 2. Systematic merger of clinical, financial, and administrative processes to manage access, cost, and quality of healthcare

primary care physician (PCP)

1. Physician who provides, supervises, and coordinates the healthcare of a member and who manages referrals to other healthcare providers and utilization of healthcare services both inside and outside a managed care plan. Family and general practitioners, internists, pediatricians, and obstetricians and gynecologists are primary care physicians 2. The physician who makes the initial diagnosis of a patient's medical condition

ancillary services

1. Tests and procedures ordered by a physician to provide information for use in patient diagnosis or treatment 2. Professional healthcare services such as radiology, laboratory, or physical therapy

security

1. The means to control access and protect information from accidental or intentional disclosure to unauthorized persons and from unauthorized alteration, destruction, or loss 2. The physical protection of facilities and equipment from theft, damage, or unauthorized access; collectively, the policies, procedures, and safeguards designed to protect the confidentiality of information, maintain the integrity and availability of information systems, and control access to the content of these systems

document imaging

1. The practice of electronically scanning written or printed paper documents into an optical or electronic system for later retrieval of the document or parts of the document if parts have been indexed; 2. The process by which paper-based documentation is captured, digitized, stored, and made available for retrieval by the end-user

documents imaging

1. The practice of electronically scanning written or printed paper documents into an optical or electronic system for later retrieval of the document or parts of the document if parts have been indexed; 2. The process by which paper-based documentation is captured, digitized, stored, and made available for retrieval by the end-user

certification

1. The process by which a duly authorized body evaluates and recognizes an individual, institution, or educational program as meeting predetermined requirements 2. An evaluation performed to establish the extent to which a particular computer system, network design, or application implementation meets a prespecified set of requirements

certification

1. The process by which a duly authorized body evaluates and recognizes an individual, institution, or educational program as meeting predetermined requirements 2. An evaluation performed to establish the extent to which a particular computer system, network design, or application implementation meets a prespecified set of requirements

Abstracting

1. The process of extracting information from a document to create a brief summary of a patient's illness, treatment, and outcome 2. The process of extracting elements of data from a source document or database and entering them into an automated system

authentication

1. The process of identifying the source of health record entries by attaching a handwritten signature, the author's initials, or an electronic signature 2. Proof of authorship that ensures, as much as possible, that log-ins and messages from a user originate from an authorized source 3. As amended by HITECH, means the corroboration that a person is the one claimed

integrity

1. The state of being whole or unimpaired 2. The ability of data to maintain its structure and attributes, including protection against modification or corruption during transmission, storage, or at rest. Maintenance of data integrity is a key aspect of data quality management and security

emergency medical treatment and active labor act (EMTALA)

A 1986 law enacted as part of the Consolidated Omnibus Reconciliation Act largely to combat "patient dumping"—the transferring, discharging, or refusal to treat indigent emergency department patients because of their inability to pay (Public Law 99-272 1986)

health information and management systems society (HIMSS)

A cause-based, not-for-profit organization exclusively focused on providing global leadership for the optimal use of IT and management systems for the betterment of healthcare

clinical data repository (CDR)

A central database that focuses on clinical information

Amendment

A clarification made to health care documentation after the original document has been signed; it should be dated, timed and signed

RxNorm

A clinical drug nomenclature developed by the Food and Drug Administration, the Department of Veterans Affairs, and HL7 to provide standard names for clinical drugs and administered dose forms

registry

A collection of care information related to a specific disease, condition, or procedure that makes health record information available for analysis and comparison

hybrid health record

A combination of paper and electronic records; a health record that includes both paper and electronic elements; also known as hybrid record

hybrid record

A combination of paper and electronic records; a health record that includes both paper and electronic elements; also known as hybrid record

serial-unit numbering system

A combination of the serial and unit numbering systems; the patient is issued a new health record number with each encounter but all of the documentation is moved from the last number to the new number

accredited standards committee (ASC X12)

A committee accredited by ANSI responsible for the development and maintenance of EDI standards for many industries. The ASC "X12N" is the subcommittee of ASC X12 responsible for the EDI health insurance administrative transactions such as 837 Institutional Health Care Claim and 835 Professional Health Care Claim forms

ethics committee

A committee tasked with reviewing clinical ethics violations to determine the course of action required to remedy the violations

decision support system

A computer-based system that gathers data from a variety of sources and assists in providing structure to the data by using various analytical models and visual tools in order to facilitate and improve the ultimate outcome in decision-making tasks associated with nonroutine and nonrepetitive problems

autonomy

A core ethical principle centered on the individual's right to self-determination that includes respect for the individual; in clinical applications, the patient's right to determine what does or does not happen to him or her in terms of healthcare

allied health professional

A credentialed healthcare worker who is not a physician, nurse, psychologist, or pharmacist (for example, a physical therapist, dietitian, social worker, or occupational therapist)

online analytical processing (OLAP)

A data access architecture that allows the user to retrieve specific information from a large volume of data

logical observations, identifiers, names and codes (LOINC)

A database protocol developed by the Regenstrief Institute for Health Care aimed at standardizing laboratory and clinical codes for use in clinical care, outcomes management, and research that enable exchange and aggregation of electronic health data from many independent systems

clinical data warehouse

A database that makes it possible to access data from multiple databases and combine the results into a single query and reporting interface

clinical data warehouse (CDW)

A database that makes it possible to access data from multiple databases and combine the results into a single query and reporting interface

data dictionary

A descriptive list of the names, definitions, and attributes of data elements to be collected in an information system or database whose purpose is to standardize definitions and ensure consistent use

outguide

A device used in paper-based health record systems to track the location of records removed from the file storage area

skilled nursing facility (SNF)

A facility which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, rehabilitative services but does not provide the level of care or treatment available in a hospital

centers for disease control and prevention (CDC)

A federal agency dedicated to protecting health and promoting quality of life through the prevention and control of disease, injury, and disability. Committed to programs that reduce the health and economic consequences of the leading causes of death and disability, thereby ensuring a long, productive, healthy life for all people

medicare

A federally funded health program established in 1965 to assist with the medical care costs of Americans 65 years of age and older as well as other individuals entitled to Social Security benefits owing to their disabilities

minmum data set (MDS) for long-term care

A federally mandated standard assessment form that Medicare- and Medicaid-certified nursing facilities must use to collect demographic and clinical data on nursing home residents; includes screening, clinical, and functional status elements

ethics

A field of study that deals with moral principles, theories, and values; in healthcare, a formal decision-making process for dealing with the competing perspectives and obligations of the people who have an interest in a common problem

acknowledgements

A form that provides a mechanism for the resident to recognize receipt of important information

credential

A formal agreement granting an individual permission to practice in a profession, usually conferred by a national professional organization dedicated to a specific area of healthcare practice; or the accordance of permission by a healthcare organization to a licensed, independent practitioner (physician, nurse practitioner, or other professional) to practice in a specific area of specialty within that organization. Usually requires an applicant to pass an examination to obtain the credential initially and then to participate in continuing education activities to maintain the credential thereafter

operative report

A formal document that describes the events surrounding a surgical procedure or operation and identifies the principal participants in the surgery

clinical transformation

A fundamental change in how medicine is practiced using health IT systems to aid in diagnosis and treatment

eHealth exchange

A group of federal agencies and non-federal organizations that came together under a common mission and purpose to improve patient care, streamline disability benefit claims, and improve public health reporting through secure, trusted, and interoperable health information exchange. Participating organizations mutually agree to support a common set of standards and specifications that enable the establishment of a secure, trusted, and interoperable connection among all participating Exchange organizations for the standardized flow of information

commission for the accreditation of birth centers

A group that surveys and accredits birth centers in the United States

straight numeric filing system

A health record filing system in which health records are arranged in ascending numerical order

unit numbering system

A health record identification system in which the patient receives a unique medical record number at the time of the first encounter that is used for all subsequent encounters

hospital

A healthcare entity that has an organized medical staff and permanent facilities that include inpatient beds and continuous medical or nursing services and that provides diagnostic and therapeutic services for patients as well as overnight accommodations and nutritional services

extended care facility

A healthcare facility licensed by applicable state or local law to offer room and board, skilled nursing by a full-time registered nurse, intermediate care, or a combination of levels on a 24-hour basis over a long period of time

medicaid

A joint federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most healthcare costs are covered if a patient qualifies for both Medicare and Medicaid

Addendum

A late entry added to a health record to provide additional information in conjunction with a previous entry. The late entry should be timely and bear the current date and reason for the additional information being added to the health record

accountable care organization (ACO)

A legal entity that is recognized and authorized under applicable state, federal, or tribal law, is identified by a Taxpayer Identification Number (TIN), and is formed by one or more ACO participant(s) that is (are) defined at 425.102(a) and may also include any other ACO participants described at 425.102(b) (42 CFR 425.20 2011)

nonmaleficence

A legal principle that means "first do no harm"

problem list

A list of illnesses, injuries, and other factors that affect the health of an individual patient, usually identifying the time of occurrence or identification and resolution

voice recognition technology

A method of encoding speech signals that do not require speaker pauses (but uses pauses when they are present) and of interpreting at least some of the signals' content as words or the intent of the speaker; Also called continuous speech recognition; continuous speech technology

systems development life cycle (SDLC)

A model used to represent the ongoing process of developing (or purchasing) information systems

national council for prescription drug programs (NCPDP)

A not-for-profit ANSI-accredited standards development organization founded in 1977 that develops standards for exchanging prescription and payment information

national cancer registrars association (NCRA)

A not-for-profit association representing cancer registry professionals and Certified Tumor Registrars (CTR). The primary focus is education and certification with the goal to ensure all cancer registry professionals have the required knowledge to be superior in their field

patient account number

A number assigned by a healthcare facility for billing purposes that is unique to a particular episode of care; a new account number is assigned each time the patient receives care or services at the facility

problem-oriented health record

A patient record in which clinical problems are defined and documented individually

master patient index

A patient-identifying directory referencing all patients related to an organization and which also serves as a link to the patient record or information, facilitates patient identification, and assists in maintaining a longitudinal patient record from birth to death

template

A pattern used in computer-based patient records to capture data in a structured manner

physician orders

A physician's written or verbal instructions to the other caregivers involved in a patient's care

statute

A piece of legislation written and approved by a state or federal legislature and then signed into law by the state's governor or the president

cloud computing

A practice that uses a vendor to archive data, and in some cases also provide application software, including an EHR, on multiple, disparate servers

consent directive

A process by which patients may opt in or opt out of having their data exchanged in the HIE

chart tracking

A process that identifies the current location of a paper record or information

record locator service (RLS)

A process that seeks information about where a patient, once identified, may have a health record available to the HIO

accreditation organizations

A professional organization that establishes the standards against which healthcare organizations are measured and conducts periodic assessments of the performance of individual healthcare organizations

key indicator

A quantifiable measure used over time to determine whether some structure, process, or outcome in the provision of care to a patient supports high-quality performance measured against best practice criteria

meaningful use

A regulation that was issued by CMS on July 28, 2010, outlining an incentive program for professionals (EPs), eligible hospitals, and CAHs participating in Medicare and Medicaid programs that adopt and successfully demonstrate meaningful use of certified EHR technology

meaningful use (MU) program

A regulation that was issued by CMS on July 28, 2010, outlining an incentive program for professionals (EPs), eligible hospitals, and CAHs participating in Medicare and Medicaid programs that adopt and successfully demonstrate meaningful use of certified EHR technology

claim

A request for payment for services, benefits, or costs by a hospital, physician or other provider that is submitted for reimbursement to the healthcare insurance plan by either the insured party or by the provider

quantitative analysis

A review of the health record to determine its completeness and accuracy

qualitative analysis

A review of the health record to ensure that standards are met and to determine the adequacy of entries documenting the quality of care

transfer record

A review of the patient's acute stay along with current status, discharge and transfer orders, and any additional instructions that accompanies the patient when he or she is transferred to another facility

chief medical informatics officer (CMIO)

A salaried physician (most often part time so that he or she retains credibility with other practicing physicians) who is heavily involved in policy development, workflow and process improvement, and ongoing maintenance of CDS and other systems requiring significant physician input

two-factor authentication

A signature type that includes at least two of the following three elements: something known, such as a password; something held, such as a token or digital certificate; and something that is personal, such as a biometric in the form of a fingerprint, retinal scan, or other

patient assessment instrument (PAI)

A standardized tool used to evaluate the patient's condition after admission to, and at discharge from, the healthcare facility

code of ethics

A statement of ethical principles regarding business practices and professional behavior

cultural audit

A strategy to define an organization's values, symbols, and routines and identify areas for improvement

drug knowledge database

A subscription service that provides current information about drugs and is accessible to users and CDS

discharge summary

A summary of the resident's stay at a healthcare facility that is used along with the postdischarge plan of care to provide continuity of care upon discharge from the facility

universal chart order

A system in which the health record is maintained in the same format while the patient is in the facility and after discharge

terminal-digit filing system

A system of health record identification and filing in which the last digit or group of digits (terminal digits) in the health record number determines file placement

numeric filing system

A system of health record identification and storage in which records are arranged consecutively in ascending numerical order according to the health record number

Alphabetic filing system

A system of health record identification and storage that uses the patient's last name as the first component of identification and his or her first name and middle name or initial for further definition

integrated health record

A system of health record organization in which all the paper forms are arranged in strict chronological order and mixed with forms created by different departments

source-oriented health record

A system of health record organization in which information is arranged according to the patient care department that provided the care

moral values

A system of principles by which one guides one's life, usually with regard to right or wrong

integrated delivery system (IDS)

A system that combines the financial and clinical aspects of healthcare and uses a group of healthcare providers, selected on the basis of quality and cost management criteria, to furnish comprehensive health services across the continuum of care

executive information system

A system that facilitates and supports senior managerial decisions

continuum of care

A system that guides and tracks patients over time through a comprehensive array of health services spanning all levels and intensity of care

point-of-care (POC) charting

A system whereby information is entered into the health record at the time and location of service

point-of-care charting

A system whereby information is entered into the health record at the time and location of service

natural language processing (NLPP

A technology that converts human language (structured or unstructured) into data that can be translated then manipulated by computer systems; branch of artificial intelligence

natural language processing (NLP)

A technology that converts human language (structured or unstructured) into data that can be translated then manipulated by computer systems; branch of artificial intelligence

telehealth

A telecommunications system that links healthcare organizations and patients from diverse geographic locations and transmits text and images for (medical) consultation and treatment

application service provider (ASP)

A third-party service company that delivers, manages, and remotely hosts standardized applications software via a network through an outsourcing contract based on fixed, monthly usage, or transaction-based pricing

system integration

A translation process that hardwires the applications together in order to be able to interoperate and exchange data seamlessly across the different applications

data use and reciprocal support agreement (DURSA)

A trust agreement entered into when exchanging information with other organizations using an agreed upon set of national standards, services and policies developed in coordination with the Office of the National Coordinator for Health Information Technology

opt in/opt out

A type of HIE model that sets the default for health information of patients to be included automatically, but the patient can opt out completely

registration-admission, discharge, transfer (R-ADT)

A type of administrative information system that stores demographic information and performs functionality related to registration, admission, discharge, and transfer of patients within the organization

registered health information administrator (RHIA)

A type of certification granted after completion of an AHIMA-accredited four-year program in health information management and a credentialing examination

registered health information technician (RHIT)

A type of certification granted after completion of an AHIMA-accredited two-year program in health information management and a credentialing examination

recovery room report

A type of health record documentation used by nurses to document the patient's reaction to anesthesia and condition after surgery

pathology report

A type of health record or documentation that describes the results of a microscopic and macroscopic evaluation of a specimen removed or expelled during a surgical procedure

managed care organization (MCO)

A type of healthcare organization that delivers medical care and manages all aspects of the care or the payment for care by limiting providers of care, discounting payment to providers of care, or limiting access to care

best of fit

A vendor strategy used when purchasing an EHR in which all the systems required by the healthcare facility are available from one vendor

best of breed

A vendor strategy used when purchasing an EHR that refers to system applications that are considered the best in their class

engage

A virtual network of AHIMA members who communicate via a web-based program managed by AHIMA

emeritus membership

AHIMA membership category for members who are 65 years old or older. Employee

new graduate membership

AHIMA membership level for student members who are recent graduates of accredited associate, bachelor's, and master's degree programs as well as AHIMA-approved coding programs

student membership

AHIMA membership level that includes any student who does not have an AHIMA credential, has not previously been an active member of AHIMA, and who is formally enrolled in a Professional Certificate Approval Program or Approved Committee for Certificate Programs, or in a CAHIIM-accredited HIM program

rules-based algorithm

Algorithm that assigns weights to specific data elements and uses those weights to compare one record to another

deterministic algorithm

Algorithm that requires exact matches in data elements such as the patient name, date of birth, and social security number

probabilistic algorithm

Algorithm that uses mathematical probabilities to determine the possibility that two patients are the same

diagnostic studies

All diagnostic services of any type, including history, physical examination, laboratory, x-ray or radiography, and others that are performed or ordered pertinent to the patient's reasons for the encounter

Centralized unit filing system

All of the patient's encounters are filed together in a single location

group membership

Allows multiple individuals from an organization to join AHIMA at one time; student and business groups are eligible for this membership type

results management

An EHR application that enables diagnostic study results (primarily lab results) to be both reviewed in a report format and the data within the reports to be processed

chart conversion

An EHR implementation activity in which data from the paper chart are converted into electronic form

clinical document architecture (CDA)

An HL7 XML-based document markup standard for the electronic exchange model for clinical documents (such as discharge summaries and progress notes). The implementation guide contains a library of CDA templates, incorporating and harmonizing previous efforts from HL7, Integrating the Healthcare Enterprise (IHE), and Health Information Technology Standards Panel (HITSP). It includes all required CDA templates for Stage I Meaningful Use, and HITECH final rule. It is commonly referred to as Consolidate CDA or C-CDA

Digital imaging and communication in medicine (DICOM)

An ISO standard that promotes a digital image communications format and picture archive and communications systems for use with digital images

web services architecture (WSA)

An architecture that utilizes web-based tools to permit communication among different software applications

public health service

An area of healthcare that deals with the health of populations in geopolitical areas, such as states and counties

stereotyping

An assumption that everyone within a certain group are the same

radio-frequency identification (RFID)

An automatic recognition technology that uses a device attached to an object to transmit data to a receiver and does not require direct contact

hospital standardization program

An early 20th-century survey mechanism instituted by the American College of Surgeons and aimed at identifying quality-of-care problems and improving patient care; precursor to the survey program offered by the Joint Commission

Digital certificate

An electronic document that establishes a person's online identity

personal health record (PHR)

An electronic or paper health record maintained and updated by an individual for himself or herself; a tool that individuals can use to collect, track, and share past and current information about their health or the health of someone in their care

electronic health record (EHR)

An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization

virtual private network (VPN)

An encrypted tunnel through the Internet that enables secure transmission of data

chief operating officer (COO)

An executive-level role responsible at a high level for day-to-day operations of an organization

remittance advice

An explanation of payments (for example, claim denials) made by third-party payers

house of delegates

An important component of the volunteer structure of the American Health Information Management Association that conducts the official business of the organization and functions as its legislative body

physician quality reporting system (PQRS)

An incentive payment system for eligible professionals who satisfactorily report data on quality measures for covered professional services furnished to Medicare beneficiaries; formerly known as the Physician Quality Reporting Initiative (PQRI)

commission on accreditation for health informatics and information management education (CAHIIM)

An independent accrediting organization whose mission is to serve the public interest by establishing and enforcing quality accreditation standards for health informatics and health information management educational programs

commission on certification for health informatics and information management (CCHIIM)

An independent body within AHIMA that establishes and enforces standards for the certification and certification maintenance of health informatics and information management professionals

joint commission

An independent, not-for-profit organization, the Joint Commission accredits and certifies more than 20,000 healthcare organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization's commitment to meeting certain performance standards

enterprise master patient index

An index that provides access to multiple repositories of information from overlapping patient populations that are maintained in separate systems and databases

physician champion

An individual who assists in communicating and educating medical staff in areas such as documentation procedures for accurate billing and appropriate EHR processes

picture archiving and communications system (PACS)

An integrated computer system that obtains, stores, retrieves, and displays digital images (in healthcare, radiological images)

hospice

An interdisciplinary program of palliative care and supportive services that addresses the physical, spiritual, social, and economic needs of terminally ill patients and their families

American Society for Testing and Materials (ASTM) International

An international organization whose purpose is to establish standards on materials, products, systems, and services

commission on accreditation of rehabilitation facilities (CARF)

An international, independent, nonprofit accreditor of health and human services that develops customer-focused standards for areas such as behavioral healthcare, aging services, child and youth services, and medical rehabilitation programs and accredits such programs on the basis of its standards

deemed status

An official designation indicating that a healthcare facility is in compliance with the Medicare Conditions of Participation

quality improvement organization (QIO)

An organization that performs medical peer review of Medicare and Medicaid claims, including review of validity of hospital diagnosis and procedure coding information; completeness, adequacy, and quality of care; and appropriateness of prospective payments for outlier cases and nonemergent use of the emergency room. Until 2002, called peer review organization

american association for accreditation of ambulatory surgery facilities (AAAASF)

An organization that provides an accreditation program to ensure the quality and safety of medical and surgical care provided in ambulatory surgery facilities

health information organization (HIO)

An organization that supports, oversees, or governs the exchange of health-related information among organizations according to nationally recognized standards

certificate authority

An organization that verifies a person's credentials and can revoke the certificate if the credentials are revoked

index

An organized (usually alphabetical) list of specific data that serves to guide, indicate, or otherwise facilitate reference to the data

database

An organized collection of data, text, references, or pictures in a standardized format, typically stored in a computer system for multiple applications

steering committee

An overarching committee comprised of key stakeholders to health information systems in general, or, less commonly, a steering committee will be convened for each specific health information system project and include only stakeholders associated with that project

unintended consequence

An unanticipated and undesired effect of implementing

issues management

Any issues that arise during the implementation are documented, brought to the attention of the vendor, and hopefully resolved, or escalated so that resolution is accomplished

claim attachment

Any of a variety of hardcopy or electronic forms needed to process a claim in addition to the claim itself, such as a copy of the emergency department note

respect

Appreciation of the value of differing perspectives, enjoyable experiences, courteous interaction, and celebration of achievements that advance our common cause

software as a service (SaaS)

Arrangement similar to an application service provider with generally less custom configuration ability and that offers a pay as you go model, where there is payment for only the actual time using the system; may be delivered via dedicated communications technology or cloud computing

transaction

As amended by HITECH, under HIPAA, the transmission of information between two parties to carry out financial or administrative activities related to health care. It includes the following types of information transmissions: (1) Health care claims or equivalent encounter information; (2) Health care payment and remittance advice; (3) Coordination of benefits; (4) Health care claim status; (5) Enrollment and disenrollment in a health plan; (6) Eligibility for a health plan; (7) Health plan premium payments; (8) Referral certification and authorization; (9) First report of injury; (10) Health claims attachments; (11) Health care electronic funds transfers (EFT) and remittance advice; (12) Other transactions that the secretary may prescribe by regulation (45 CFR 160.103 2013)

use

As amended by HITECH, with respect to individually identifiable health information, the sharing, employment, application, utilization, examination, or analysis of such information within an entity that maintains such information (45 CFR 160.103 2013)

clinical coding

Assigning codes to represent diagnoses and procedures

change control program

Assures that there is documented approval for the change to be made and evidence that all elements of implementation, testing, rollout, training, and such are performed

identity proofing

Authentication credentials used to electronically sign prescriptions

structured data

Binary, machine-readable data in discrete fields; data able to be processed by the computer

alphanumeric filing system

Both alphabetic and numeric characters are used to sort health records in this system

clinical decision support system (CDSS)

CDS that requires the combination of data from more than one sources and the ability to deliver the alert back to the appropriate system or systems

value-based purchasing (VBP)

CMS incentive plan that links payments more directly to the quality of care provided and rewards providers for delivering high-quality and efficient clinical care. It incorporates clinical process-of-care measures as well as measures from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey on how patients view their care experiences

medical staff privileges

Categories of clinical practice privileges assigned to individual practitioners on the basis of their qualifications

administrative data

Coded information contained in secondary records, such as billing records, describing patient identification, diagnoses, procedures, and insurance

national drug codes (NDC)

Codes that serve as product identifiers for human drugs, currently limited to prescription drugs and a few selected over-the-counter products

component state associations (CSAs)

Component state associations are part of the volunteer structure of AHIMA and are organized in every state, the District of Columbia, and the Commonwealth of Puerto Rico. The purpose of each Component State Association shall be to promote the mission and purpose of AHIMA in its state

integrated delivery network (IDN)

Comprises a group of hospitals, physicians, other providers, insurers, or community agencies that work together to deliver health services

ethical principles

Concepts such as altruism, beneficence, consequentialism, deontology, egoism, least harm, and utilitarianism, upon which ethical decisions are made

medical device integration

Connecting medical devices to the EHR

Aggregate Data

Data extracted from individual health records and combined to form de-identified information about groups of patients that can be compared and analyzed

information

Data processed into usable form

free-text data

Data that are narrative in nature

discrete data

Data that represent separate and distinct values or observations; that is, data that contain only finite numbers and have only specified values

metadata

Descriptive data that characterize other data to create a clearer understanding of their meaning and to achieve greater reliability and quality of information. Metadata consist of both indexing terms and attributes. Data about data: for example, creation date, date sent, date received, last access date, last modification date

requirements specification

Determining and documenting the detailed features and functions desired in the system in order to meet the organization's specific goals

auto-analyzer

Device that analyzes the specimen

subjective, objective, assessment, plan (SOAP)

Documentation method that refers to how each progress note contains documentation relative to subjective observations, objective observations, assessments, and plans

consultation report

Documentation of the clinical opinion of a physician other than the primary or attending physician

loose material

Documentation that needs to be filed in the health record

legal health record

Documents and data elements that a healthcare provider may include in response to legally permissible requests for patient information

correction

Edit made to the health record by drawing a single line through the erroneous information and writing the word "error" above the mistake; the practitioner should sign, date and time the correction

computerized provider order entry (CPOE)

Electronic prescribing systems that allow physicians to write prescriptions and transmit them electronically. These systems usually contain error prevention software that provides the user with prompts that warn against the possibility of drug interaction, allergy, or overdose and other relevant information

bias

Favoritism, partiality, or prejudice

go-live

First use of the system in actual practice

vendor selection

Formal process by a healthcare organization that is just starting to acquire health information systems or replacing entire set of components with new components; steps in the process include needs identification, requirements specification, request for proposal (RFP), analysis of RFP responses, due diligence, and contract negotiation.

association for healthcare documentation integrity (AHDI)

Formerly the American Association for Medical Transcription (AAMT), the AHDI has a model curriculum for formal educational programs that includes the study of medical terminology, anatomy and physiology, medical science, operative procedures, instruments, supplies, laboratory values, reference use and research techniques, and English grammar

heath level seven (HL7)

Founded in 1987, Health Level Seven International (HL7) is a not-for-profit, ANSI-accredited standards-developing organization dedicated to providing a comprehensive framework and related standards for the exchange, integration, sharing, and retrieval of electronic health information that supports clinical practice and the management, delivery, and evaluation of health services

consolidated clinical document architecture (C-CDA)

HL7-created document templates

laboratory information system (LIS)

Health information system that includes hardware; software; communications and network technologies; operational and cultural adaptations that people must make to use the technologies in performing diagnostic studies on various specimens collected from patients and to apply professional judgment in evaluating the quality of the data representing the results; policies and standards from the local organization in which the system is housed as well as accrediting and licensing bodies that must be followed for design of the technology and its use; and workflow and process designs assure the most efficient and effective use of the technology

paper health record

Health record that is completely available in paper media

retrospective documentation

Healthcare providers add documentation after care has been given, possibly for the purpose of increasing reimbursement or avoiding a medical legal action

evidence-based medicine

Healthcare services based on clinical methods that have been thoroughly tested through controlled, peer-reviewed biomedical studies

turnaround time

In an ROI system, the time between receipt of request and when the request is sent to requester

guidelines

In forms control, provides general direction about the design of the form

protocol

In healthcare, a detailed plan of care for a specific medical condition based on investigative studies; in medical research, a rule or procedure to be followed in a clinical trial; in a computer network, a rule or procedure used to address and ensure delivery of data

resident assessment instrument (RAI)

In skilled nursing facilities, the care plan is based on a format required by federal regulations

active membership

Individuals interested in the AHIMA purpose and willing to abide by the Code of Ethics are eligible for active membership. Active members in good standing shall be entitled to all membership privileges including the right to vote

claims data

Information required to be reported on a healthcare claim for service reimbursement

patient portal

Information system that allows patient to log in to obtain information, register, and perform other functions

billing system

Information system that generates a bill for healthcare services performed

patient financial system (PFS)

Information system that manages patient accounts

closed-loop medication management

Information systems used to provide patient safety when ordering and administering medications

demographics

Information used to identify an individual, such as name, address, gender, age, and other information linked to a specific person; also known as demographic data

continuity of care record (CCR)

Is a core data set of the most relevant administrative, demographic, and clinical information about a patient's healthcare, covering one or more healthcare encounters. It provides a means for one healthcare practitioner, system, or setting to aggregate all of the pertinent data about a patient and forward it to another practitioner, system, or setting to support the continuity of care

federal health IT strategic plan 2015-2020

Issued by the Office of the National Coordinator for Health Information Technology (ONC), this plan describes a vision of high-quality care, lower costs, healthy population, and engaged people and mission to improve the health and well-being of individuals and communities through the use of technology and health information that is accessible when and where it matters most

direct project

Launched in March 2010 to offer a simpler, standards-based way for participants to send authenticated, encrypted health information directly to known recipients over the Internet

consent to treatment

Legal permission given by a patient or a patient's legal representative to a healthcare provider that allows the provider to administer care and treatment or to perform surgery or other medical procedures

health information technology for economic and clinical health (HITECH)

Legislation created to promote the adoption and meaningful use of health information technology in the United States. Subtitle D of the Act provides for additional privacy and security requirements that will develop and support electronic health information, facilitate information exchange, and strengthen monetary penalties. Signed into law on February 17, 2009, as part of ARRA (Public Law 111-5 2009)

health information technology for economic and clinical health (HITECH) act

Legislation created to promote the adoption and meaningful use of health information technology in the United States. Subtitle D of the Act provides for additional privacy and security requirements that will develop and support electronic health information, facilitate information exchange, and strengthen monetary penalties. Signed into law on February 17, 2009, as part of ARRA (Public Law 111-5 2009)

utilization review act

Legislation in 1977 that made it a requirement for hospitals to conduct continued-stay reviews for Medicare and Medicaid patients

home healthcare

Limited part-time or intermittent skilled nursing care and home health aide services, physical therapy, occupational therapy, speech-language therapy, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), medical supplies, and other services

contraindication

Medication should not be prescribed due to another medication or condition

speech dictation

Method of collecting information in an information system through spoken word

semantic interoperability

Mutual understanding of the meaning of data exchanged between information systems

sunsetting

No longer selling or supporting a product

e-visits

Non-face-to-face interaction between patient and provider

unstructured data

Nonbinary, human-readable data

workstations on wheels (WoWs)

Notebook computers mounted on carts that can be moved through the facility by users

deficiency slip

Notification when a document or signature is missing that identifies the pertinent document and what needs to be done (dictated, completed, and signed)

shared nationwide interoperability roadmap

ONC's three stage vision for interoperability; 2015-2017: Nationwide ability to send, receive, find, and use a common clinical data set; 2018 - 2020: Expand interoperable data, users, sophistication, and scale; 2021 - 2024: Broad-scale learning health system

prejudice

Occurs when a person is judged solely based on cultural factors such as ethnicity, religion, age, gender, sexual orientation, or such

duplicate health record

Occurs when the patient has two or more health record numbers issued; the patient's medical information becomes fragmented with some information under the first number and the remainder under the second

subacute care

Offers patients access to constant nursing care while recovering at home

CONNECT

Open-source software that implements health exchange specifications; it enables discovery of where there may be information as well as directly retrieving it from the source

standing orders

Orders the medical staff or an individual physician has established as routine care for a specific diagnosis or procedure

association of record librarians of North America (ARLNA)

Organization formed 10 years after the beginning of the hospital standardization movement whose original objective was to elevate the standards of clinical recordkeeping in hospitals, dispensaries, and other healthcare facilities; precursor of the American Health Information Management Association

radiology information system (RIS)

Performs functions similar to LIS, receiving an order for a procedure, scheduling it, notifying hospital personnel or the patient if performed as an outpatient, tracking the performance of the procedure and its output, tracking preparation of the report, performing quality control, maintaining an inventory of equipment and supplies, and managing departmental staffing and budget

end user

Persons who will use the system for their daily processes

provider

Physician, clinic, hospital, nursing home, or other healthcare entity (second party) that delivers healthcare services

medical history

Portion of clinical data that addresses the patient's current complaints and symptoms and lists his or her past medical, personal, and family history

patient safety

Preventing harm to patients, learning from errors, and building a culture of safety

prior authorization

Process of obtaining approval from a healthcare insurance company before receiving healthcare services

medication reconciliation

Process that monitors and confirms that the patient receives consistent dosing across all facility transfers, such as on admission, from nursing unit to surgery, and from surgery to ICU

fellowship program

Program of earned recognition for AHIMA members who have made significant and sustained contributions to the HIM profession through meritorious service, excellence in professional practice, education, and advancement of the profession through innovation and knowledge sharing

message format standards

Protocols that help ensure that data transmitted from one system to another remain comparable

identity management

Provides security functionality, including determining who (or what information system) is authorized to access information, authentication services, audit logging, encryption, and transmission controls

system

Refers to all the components (technology, standards, people, policy, and process) that must work together to achieve a desired goal (interoperability)

analytics

Refers to statistical processing of data to reveal new information

implement

Refers to technology having been installed, configured to meet the basic requirements of the healthcare organization, and demonstrated to users ation

value

Refers to the combination of quality and cost

revenue cycle management (RCM)

Refers to the entire process of creating, submitting, analyzing, and obtaining payment for healthcare services

medical staff classification

Refers to the organization of physicians according to clinical assignment

optimization

Reflects not only good adoption for all routine operations, but also an understanding and appropriate use of the technology's features

adoption

Reflects the fact that the organization has implemented all of the major components of technology, although there may be some available technology that is more specialized, costly, or time-consuming to implement that has not yet been implemented

scorecards

Reports of outcomes measures to help leaders know what they have accomplished

dashboard

Reports of process measures to help leaders follow progress to assist with strategic planning

requisition

Request for the health record

analysis

Review of health record for proper documentation and adherence to regulatory and accreditation standards

identity matching algorithm

Rules established in an information system that predicts the probability that two or more patients in the database are the same patient

operating rules

Rules that further explain the business requirements so their use is consistent across health plans

concurrent review

Screening for medical necessity and the appropriateness and timeliness of the delivery of medical care from the time of admission until discharge

overlay

Situation in which a patient is issued a medical record number that has been previously issued to a different patient

overlap

Situation in which a patient is issued more than one medical record number from an organization with multiple facilities

cultural competence

Skilled in awareness, understanding, and acceptance of beliefs and values of the people of groups other than one's own

kiosk

Special form of input device geared more to people less familiar with computers

encoder

Specialty software used to facilitate the assignment of diagnostic and procedural codes according to the rules of the coding system

core measures

Standardized performance measures developed to improve the safety and quality of healthcare

conditions for coverage

Standards applied to facilities that choose to participate in federal government reimbursement programs such as Medicare and Medicaid

medical staff bylaws

Standards governing the practice of medical staff members; typically voted upon by the organized medical staff and the medical staff executive committee and approved by the facility's board; governs the business conduct, rights, and responsibilities of the medical staff; medical staff members must abide by these bylaws in order to continue practice in the healthcare facility

SMART goals

Statements that identify results that are: Specific, Measurable, Attainable, Relevant, and Time-based

health reform

Steps taken to make major policy changes in how providers are reimbursed for healthcare services

document management system

System commonly used when transitioning from paper-based to electronic health record that scans the paper record and stores it digitally

client/server system

System in which the healthcare organization has commercial software installed on servers housed and maintained within the organization itself, housed within the organization and managed by an outsourced company, or housed and maintained by a contractor for the healthcare organization

automated drug dispensing machines

System that makes drugs available for patient care

nursing information system

System that manages the nursing department, including staffing, credentialing, training, budgeting, and other managerial functions

clinical documentation system

System that supplies templates to the user to be completed primarily via point-and-click, drop-down, type-ahead, and other data-entry tools

barcode medication administration record (BC-MAR)

System that uses barcoding technology for positive patient identification and drug information

serial numbering system

System where a patient is issued a unique numerical identifier for every encounter at the healthcare facility; if a patient is admitted to the healthcare facility five times he or she will have five different health record numbers

content management systems

Systems that help maintain patient preferences about who may have access to their health information

ancillary systems

Systems that serve primarily to manage the department in which they exist, while at the same time providing key clinical data for the EHR

American academy of professional coders

The American Academy of Professional Coders provides certified credentials to medical coders in physician offices, hospital outpatient facilities, ambulatory surgical centers, and in payer organizations

centers for medicare and medicaid services (CMS)

The Department of Health and Human Services agency responsible for Medicare and parts of Medicaid. Historically, CMS has maintained the UB-92 institutional EMC format specifications, the professional EMC NSF specifications, and specifications for various certifications and authorizations used by the Medicare and Medicaid programs. CMS is responsible for the oversight of HIPAA administrative simplification transaction and code sets, health identifiers, and security standards. CMS also maintains the HCPCS medical code set and the Medicare Remittance Advice Remark Codes administrative code set

SCRIPT

The NCPDP standard developed for electronically transmitting a prescription

information governance

The accountability framework and decision rights to achieve enterprise information management (EIM). IG is the responsibility of executive leadership for developing and driving the IG strategy throughout the organization. IG encompasses both data governance (DG) and information technology governance (ITG)

registration

The act of enrolling

due diligence

The actions associated with making a good decision, including investigation of legal, technical, human, and financial predictions and ramifications of proposed endeavors with another party

conditions of participation

The administrative and operational guidelines and regulations under which facilities are allowed to take part in the Medicare and Medicaid programs; published by the Centers for Medicare and Medicaid Services, a federal agency under the Department of Health and Human Services

learning health system

The alignment of science, informatics, incentives, and culture for continuous improvement and innovation, with best practices seamlessly embedded in the delivery process and new knowledge captured as an integral by-product of the delivery experience

clinical privileges

The authorization granted by a healthcare organization's governing board to a member of the medical staff that enables the physician to provide patient services in the organization within specific practice limits

interoperability

The capability of different information systems and software applications to communicate and exchange data

hospital information system (HIS)

The comprehensive database containing all the clinical, administrative, financial, and demographic information about each patient served by a hospital

system configuration

The creation of data dictionaries, tables, decision support rules, templates for data entry, screen layouts, and reports used in a system; also known as system build

system build

The creation of data dictionaries, tables, decision support rules, templates for data entry, screen layouts, and reports used in a system; also known as system configuration

Data

The dates, numbers, images, symbols, letters, and words that represent basic facts and observations about people, processes, measurements, and conditions

data

The dates, numbers, images, symbols, letters, and words that represent basic facts and observations about people, processes, measurements, and conditions

quality

The degree or grade of excellence of goods or services, including, in healthcare, meeting expectations for outcomes of care

progress notes

The documentation of a patient's care, treatment, and therapeutic response, which is entered into the health record by each of the clinical professionals involved in a patient's care, including nurses, physicians, therapists, and social workers

board of directors

The elected or appointed group of officials who bear ultimate responsibility for the successful operation of a healthcare organization

business intelligence (BI)

The end product or goal of knowledge management

health information exchange (HIE)

The exchange of health information electronically between providers and others with the same level of interoperability, such as labs and pharmacies

health information exchange (HIE)

The exchange of health information electronically between providers and others with the same level of interoperability, such as labs and pharmacies

heath insurance portability and accountability act of 1996 (HIPPA)

The federal legislation enacted to provide continuity of health coverage, control fraud and abuse in healthcare, reduce healthcare costs, and guarantee the security and privacy of health information; limits exclusion for pre-existing medical conditions, prohibits discrimination against employees and dependents based on health status, guarantees availability of health insurance to small employers, and guarantees renewability of insurance to all employees regardless of size; requires covered entities (most healthcare providers and organizations) to transmit healthcare claims in a specific format and to develop, implement, and comply with the standards of the Privacy Rule and the Security Rule; and mandates that covered entities apply for and utilize national identifiers in HIPAA transactions (Public Law 104-191 1996)

health informatics

The field of information science concerned with the management of all aspects of health data and information through the application of computers and computer technologies

medical identity theft

The fraudulent use of an individual's identifying information in a healthcare setting

data abstraction

The identification of data elements by an individual through health record review

clinical data

The information that reflects the treatment and services provided to the patient as well as how the patient responded to such treatment and services

knowledge

The information, understanding, and experience that give individuals the power to make informed decisions

licensure

The legal authority or formal permission from authorities to carry on certain activities that by law or regulation require such permission (applicable to institutions as well as individuals)

Average length of stay (ALOS)

The mean length of stay for hospital inpatients discharged during a given period of time. 25 days or less

american medical record association (AMRA)

The name adopted by the American Association of Medical Record Librarians in 1970; precursor of the American Health Information Management Association

american association of medical record librarians (AAMRL)

The name adopted by the Association of Record Librarians of North America in 1944; precursor of the American Health Information Management Association

patient acuity staffing

The number of nurses and other care providers is based on how sick the patient is

clinical observations

The observations of physicians, nurses, and other caregivers in order to create a chronological report of the patient's condition and response to treatment during his or her hospital stay

retrospective review

The part of the utilization review process that concentrates on a review of clinical information following patient discharge

care areas assessments (CAAs)

The patient is assessed and reassessed at defined intervals as well as whenever there is a significant change in his or her condition

blanket authorization

The patient signs an authorization allowing the release of information specialist to release any and all information from that point forward

cultural diversity

The perceived or actual difference among people

history and physical (H&P)

The pertinent information about the patient, including chief complaint, past and present illnesses, family history, social history, and review of body systems

biometrics

The physical characteristics of users (such as fingerprints, voiceprints, retinal scans, iris traits) that systems store and use to authenticate identity before allowing the user access to a system

physical examination

The physician's assessment of the patient's current health status after evaluating the patient's physical condition

upcoding

The practice of assigning diagnostic or procedural codes that represent higher payment rates than the codes that actually reflect the services provided to patients

healthcare data analytics

The practice of using data to make business decisions in healthcare

unbundling

The practice of using multiple codes to bill for the various individual steps in a single procedure rather than using a single code that includes all of the steps of the comprehensive procedure

office of the national coordinator (ONC) for health information technology

The principal federal entity charged with coordination of nationwide efforts to implement and use the most advanced health information technology and the electronic exchange of health information. The position of National Coordinator was created in 2004, through an Executive Order, and legislatively mandated in the HITECH Act of 2009

clinical data analytics

The process by which health information is captured, reviewed, and used to measure quality

clinical decision support ( CDS)

The process in which individual data elements are represented in the computer by a special code to be used in making comparisons, trending results, and supplying clinical reminders and alerts

clinical decision support (CDS)

The process in which individual data elements are represented in the computer by a special code to be used in making comparisons, trending results, and supplying clinical reminders and alerts

record reconciliation

The process of assuring that all the records of discharged patients have been received by the HIM department for processing

charge capture

The process of collecting all services, procedures, and supplies provided during patient care

storage management

The process of determining on what type of media to store data, how rapidly data must be accessible, arranging for replication of storage for back up and disaster recovery, and where storage systems should be maintained

utilization review

The process of determining whether the medical care provided to a specific patient is necessary according to preestablished objective screening criteria at time frames specified in the organization's utilization management plan

release of information

The process of disclosing patient-identifiable information from the health record to another party

Data mining

The process of extracting and analyzing large volumes of data from a database for the purpose of identifying hidden and sometimes subtle relationships or patterns and using those relationships to predict behaviors

data mining

The process of extracting and analyzing large volumes of data from a database for the purpose of identifying hidden and sometimes subtle relationships or patterns and using those relationships to predict behaviors

computer-assisted coding ( CAC)

The process of extracting and translating dictated and then transcribed free-text data (or dictated and then computer-generated discrete data) into ICD-10-CM and CPT evaluation and management codes for billing and coding purposes

data capture

The process of recording healthcare-related data in a health record system or clinical database

american health information management association (AHIMA)

The professional membership organization for managers of health record services and healthcare information systems as well as coding services; provides accreditation, advocacy, certification, and educational services

American recovery and reinvestment act (ARRA)

The purposes of this act include the following: (1) To preserve and create jobs and promote economic recovery. (2) To assist those most impacted by the recession. (3) To provide investments needed to increase economic efficiency by spurring technological advances in science and health. (4) To invest in transportation, environmental protection, and other infrastructure that will provide long-term economic benefits. (5) To stabilize state and local government budgets, in order to minimize and avoid reductions in essential services and counterproductive state and local tax increases

American Recover and Reinvestment Act (ARRA)

The purposes of this act include the following: (1) To preserve and create jobs and promote economic recovery. (2) To assist those most impacted by the recession. (3) To provide investments needed to increase economic efficiency by spurring technological advances in science and health. (4) To invest in transportation, environmental protection, and other infrastructure that will provide long-term economic benefits. (5) To stabilize state and local government budgets, in order to minimize and avoid reductions in essential services and counterproductive state and local tax increases

privacy

The quality or state of being hidden from, or undisturbed by, the observation or activities of other persons, or freedom from unauthorized intrusion; in healthcare-related contexts, the right of a patient to control disclosure of protected health information

online transaction processing (OLTP)

The real-time processing of day-to-day business transactions from a database

documentation

The recording of pertinent healthcare findings, interventions, and responses to treatment as a business record and form of communication among caregivers

need to know principle

The release-of-information principle based on the minimum necessary standard

data quality

The reliability and effectiveness of data for its intended uses in operations, decision making, and planning

anesthesia report

The report that notes any preoperative medication and response to it, the anesthesia administered with dose and method of administration, the duration of administration, the patient's vital signs while under anesthesia, and any additional products given the patient during a procedure

continuity of care document (CCD)

The result of ASTM's Continuity of Care Record standard content being represented and mapped into the HL7's Clinical Document Architecture specifications to enable transmission of referral information between providers; also frequently adopted for personal health records

medication five rights

The right drug, in the right dose, through the right route, at the right time, and to the right patient

data analytics

The science of examining raw data with the purpose of drawing conclusions about that information. It includes data mining, machine language, development of models, and statistical measurements. Analytics can be descriptive, predictive, or prescriptive

american college of surgeons (ACS)

The scientific and educational association of surgeons formed to improve the quality of surgical care by setting high standards for surgical education and practice

chief nursing officer (CNO)

The senior manager (usually a registered nurse with advanced education and extensive experience) responsible for administering patient care services

chief executive officer (CEO)

The senior manager appointed by a governing board to direct an organization's overall long-term strategic management

chief financial officer (CFO)

The senior manager responsible for the fiscal management of an organization

chief information officer (CIO)

The senior manager responsible for the overall management of information resources in an organization

values

The social and cultural belief system of a person or a healthcare organization

care plan

The specific goals in the treatment of an individual patient, amended as the patient's condition requires, and the assessment of the outcomes of care; serves as the primary source for ongoing documentation of the resident's care, condition, and needs

expressed consent

The spoken or written permission granted by a patient to a healthcare provider that allows the provider to perform medical or surgical services

medical staff

The staff members of a healthcare organization who are governed by medical staff bylaws; may or may not be employed by the healthcare organization

data conversion

The task of moving data from one data structure to another, usually at the time of a new system installation

implied consent

The type of permission that is inferred when a patient voluntarily submits to treatm

culture

The values, beliefs, attitudes, languages, symbols, rituals, behaviors, and customs unique to a particular group of people

interface

The zone between different computer systems across which users want to pass information (for example, a computer program written to exchange information between systems or the graphic display of an application program designed to make the program easier to use)

pharmacy information system

This system receives an order for a drug in a hospital, aids the hospital's pharmacist in checking for contraindications, directs staff in compounding any drugs requiring special preparation, aids in dispensing the drug in the appropriate dose and for the appropriate route of administration, maintains inventory (documenting medications in stock using the National Drug Code, the terminology maintained by the Food and Drug Administration [FDA] for use in identifying FDA-approved drugs), supports staffing and budgeting, and performs other departmental operations

continuing education units (CEUs)

Training that enables employees to remain current with advancing knowledge in their profession; activities that qualify for CEUs include such things as attending workshops and seminars, taking college courses, participating in independent study activities, and engaging in self-assessment activities

discrete reportable transcription (DRT)

Transcription system that combines speech dictation with natural language processing

ambulatory

Treatment provided on an outpatient basis

health IT

Under HITECH, hardware, software, integrated technologies or related licenses, intellectual property, upgrades, or packaged solutions sold as services that are designed for or support the use by health care entities or patients for the electronic creation, maintenance, access, or exchange of health information (Public Law 111-5 2009)

breach

Under HITECH, the acquisition, access, use, or disclosure of protected health information in a manner not permitted under subpart E of this part that compromises the security or privacy of the protected health information (45 CFR 164.402 2013)

ambulatory surgery center/ ambulatory surgical center (ASC)

Under Medicare, an outpatient surgical facility that has its own national identifier; is a separate entity with respect to its licensure, accreditation, governance, professional supervision, administrative functions, clinical services, recordkeeping, and financial and accounting systems; has as its sole purpose the provision of services in connection with surgical procedures that do not require inpatient hospitalization; and meets the conditions and requirements set forth in the Medicare Conditions of Participation

peer review organization (PRO)

Until 2002, a medical organization that performed a professional review of medical necessity, quality, and appropriateness of healthcare services provided to Medicare beneficiaries

claims status inquiry and response

Used to determine if a health plan has ended a claim for additional information or is processing the claim

power user

Users who are able to use technology to significantly improve their productivity

eligibility verification

Verification that determines if a patient's health plan will provide reimbursement for services to be performed, and sometimes prior-authorization management systems where a health plan requires review and approval of a procedure (or referral) prior to performing the service

big data

Very large volume of data that offers greater reliability and validity

leadership

Visionary thinking, decisions responsive to membership and mission, and accountability for actions and outcomes

e-Prescribing (e-Rx)

When a prescription is written from the personal digital assistant and an electronic fax or an actual electronic data interchange transaction is generated that transmits the prescription directly to the retail pharmacy's information system

alert fatigue

When an excessive number of alerts are used in an information system, users get tired of looking at the alerts and may ignore them

portals

Windows into information systems

documentation standards

Within the context of healthcare, describe those principles, codes, beliefs, guidelines, and regulations that guide health record documentation

autopsy report

Written documentation of the findings from a postmortem pathological examination

beneficence

a legal term that means promoting good for others or providing services that benefit others, such as releasing health information that will help a patient receive care or will ensure payment for services received

individual users

depends on the health record in order to complete their job. ex. patient care provider, patient care manager and support staff, coding and billing, patients employers, lawyers, law enforcement, government policy makers

institutional users

need access to health records in order to complete their mission. ex.healthcare delivery organizations, third-party payers, medical review organizations, research organizations, educational organizations, accreditation organizations, government licensing agencies, policy-making bodies

secondary purpose

not related specifically to patient care. ex. education of health professionals, legal, accreditation, policy development , public health and research

double billing

occurs when two providers bill for one service provided to one patient

primary purpose

related to provide care for patients. ex. patient care, management go patient care, administrative purpose